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Headache,Weakness, and Dizziness-1
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1. A 21-year-old college student is brought by her roommate to the emergency department (ED). The roommate states that earlier in the day the patient complained of a severe headache, stiff neck, and On their way to the ED, the roommate states that the patient was con- fused. Her vital signs are blood pressure (BP) 110/80 mm Hg, heart rate (HR) 110 beats per minutes, respiration rate (RR) 16 breaths per minute, and temperature 102°F. What is the next step in the management of this patient?
- Start empiric antibiotics, noncontrast head computed tomography (CT) before performing lumbar puncture (LP).
- Order a noncontrast head CT and start antibiotics once the results are back.
- Give 1 g of acetaminophen, start fluid hydration, and perform an LP.
- Perform an LP and start antibiotics once the results are back.
- Order a noncontrast head CT, perform an LP, then start antibiotics.
2. A 29-year-old woman presents to the ED complaining of a general- ized headache over the last 2 She has seen many doctors for it but has yet to get a correct diagnosis. She describes the headache as moderate in intensity and worse with eye movement. Occasionally, it awakes her from sleep and is worse when tying her shoes. She is scared because her vision gets blurry for a few minutes every day. Her only medication is acetaminophen and an oral contraceptive. Her BP is 140/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. On physical examination you appreciate papilledema. Which of the following is the most appropriate next step in management?
- Consult neurosurgery.
- Administer 2 g of ceftriaxone then perform an LP rule out meningitis.
- Order a magnetic resonance imaging (MRI) to look for a carotid artery dissection.
- Diagnose a migraine headache and prescribe her a triptan.
- Perform a CT scan, and if negative perform, an LP specifically to measure the opening pressure.
3. A 67-year-old woman presents to the ED complaining of a 2-day history of general malaise, subjective fevers, chills, diffuse headache, and right-sided jaw She also notes diminished vision in her right eye. Her symptoms are minimally relieved with acetaminophen. She denies any sick contacts. The patient’s vitals include an oral temperature of 100.6°F, HR is 95 beats per minute, BP is 130/75 mm Hg, and RR is 16 breaths per minute with oxygen saturation of 99% on room air. She is tender on the right side of her scalp. You initiate empirical treatment. Which of the following tests will confirm your diagnosis?
- Influenza A/B assay
- Rapid strep test
- Erythrocyte sedimentation rate (ESR)
- Complete blood count (CBC)
- Temporal artery biopsy
4. A 25-year-old stockbroker presents to the ED complaining of 6 weeks of daily Her headaches are band-like in distribution and are not associated with nausea, vomiting, visual phenomena, or neurologic symp- toms. Normally they respond to acetaminophen, but they have increased in frequency in the past week as she stopped taking a medication that had been prescribed to prevent them. What type of primary headache syn- drome is the patient likely experiencing?
- Migraine headaches
- Cluster-type headaches
- Trigeminal neuralgia
- Postherpetic neuralgia
- Tension headache
5. A 22-year-old woman presents to the ED complaining of She states that while at home, she experienced a headache that was associ- ated with blurry vision in both eyes with a shimmering line in her vision. She subsequently lost her vision and felt uncoordinated, followed by increased pain at the base of her skull. Upon arrival in the ED, her vision returned to normal. A head CT scan and an LP are both negative. She now complains of a persistent, severe, pulsatile headache. She has had two similar episodes in the past year with the headache refractory to over-the-counter medica- tions. Which of the following is likely to relieve her symptoms?
- High-flow oxygen
- LP with removal of 15-cc cerebrospinal fluid (CSF)
6. A 25-year-old man presents to the ED complaining of headache for 2 He describes the pain as pulsatile and occipital. The patient had an LP 3 days back and was diagnosed with viral meningitis after 4 days of symptoms. Noncontrast head CT at that time was normal. He improved shortly thereafter with defervescence of his fever and resolution of his con- stitutional and nuchal symptoms. He states that his new headache is dif- ferent than his previous in that it is exacerbated by standing or sitting upright and is relieved by sitting down and is not associated with photo- phobia or neck stiffness. The headache is not relieved by over-the-counter pain medications. He is afebrile and nontoxic appearing. Which of the following is definitive therapy for this patient’s headache?
- A 1-L bolus of intravenous (IV) normal saline
- Treatment with standard pharmacologic agents for migraine
- Treatment with meclizine
- Consultation with anesthesia for a blood patch
- Repeat LP to improve symptoms
7. A 27-year-old woman with known idiopathic intracranial hypertension (IIH) presents to the ED complaining of a bifrontotemporal headache several times a day for 6 weeks after running out of her She complains of occasional pulsatile tinnitus but no visual disturbances. Fun- duscopic examination reveals no papilledema and normal venous pulsations. Which of the following factors determines the need for urgent treatment in patients with IIH?
- The presence of papilledema on funduscopic examination
- A history of pulsatile tinnitus
- Presence of an empty sella on CT scan
- Complaint of visual loss or visual disturbances
- A history of concomitant minocycline use
8. A 57-year-old man with a past medical history of hypertension and migraines presents to the ED complaining of a headache that started 2 days ago. He states the headache began suddenly with peak intensity while he was The pain is continuous particularly in the occipital region and is associated with mild nuchal rigidity and mild photophobia. He denies having a recent fever. A noncontrast head CT is obtained and is normal. Which of the following is the most appropriate next step in management?
- Metoclopramide for nausea relief and ketorolac (Toradol) for pain control
- Empiric treatment for meningitis with IV antibiotics
- IV mannitol to lower intracranial pressure (ICP)
- Angiography to evaluate for an aneurysm
9. A 27-year-old woman presents to the ED complaining of headache lasting approximately 1 hour in duration that is unrelieved by aspirin and acetaminophen. She states the headache was not preceded by any visual phenomena, is left sided, pulsatile, and has occurred nearly monthly coin- ciding with her menstrual period for the past 6 She also complains of nausea and sensitivity to sound and light. Which of the following is the most appropriate therapy for this patient at the time of presentation?
- IV morphine sulfate
- Another trial of aspirin and acetaminophen
- Sumatriptan (Imitrex)
- Topiramate (Topamax)
- Hydromorphone and acetaminophen
10. A 55-year-old woman presents to the ED complaining of 1 day of a left- sided headache that is associated with scalp and ear She describes the pain as gradual in onset, dull, and constant. She describes a week of constitu- tional symptoms before the onset of her headache syndrome, including joint pain, tenderness of the muscles of her lower extremities, and fatigue. She is afebrile with no nuchal symptoms, photophobia, or phonophobia. Physical examination reveals a tender scalp and a thickened, painful temporal artery. Which of the following is the most appropriate next step in management?
- Initiate corticosteroid therapy.
- LP to rule out subarachnoid hemorrhage (SAH).
- Injection of lidocaine at the base of the occiput.
- Initiate antibiotic therapy.
- Send an ESR.
11. A 28-year-old male military recruit presents to the ED complaining of headache, fever, and neck His temperature is 102.2°F and he refuses to move his neck. He is somewhat lethargic appearing and winces when the lights are turned on in the examining room. He has a nonfocal neurologic examination and you proceed with LP. Which of the following is the most specific finding for suspected bacterial meningitis?
- The presence of phonophobia, photophobia, and neck stiffness
- Fever higher than 102.2°F
- Elevated polymorphonuclear white blood cell (WBC) count on CSF analysis
- Elevated protein on CSF analysis
- Increased glucose on CSF analysis
12. As a senior resident in the ED, an intern calls you over to see a patient he treated for a migraine The patient is a 21-year-old woman with a history of poorly controlled migraines. The patient was using a number of migraine medications at home and several were administered intrave- nously. When you approach the patient, you note her tongue is protruding and her head is tilted to the left. She is grimacing. The intern is concerned that the patient is having an acute stroke and would like to obtain a head CT scan. You advise the intern that the symptoms are likely the result of a medication side effect. Which of the following medications is likely to have caused the patient’s symptoms?
- Morphine sulfate
13. A 63-year-old man who lives in a homeless shelter presents to the ED complaining of headache with photophobia for 6 Upon arrival to the ED, the triage nurse places him in an isolation room. The triage note states that the patient was alert and conversant during the nursing inter- view. You enter the isolation room and attempt to speak to the patient, but he is lethargic and combative. You note that his temperature is 103°F. He is unwilling to move his neck and winces when you attempt to check his pupillary reflexes with a penlight. The nurse informs you that laboratory analyses are delayed this evening because of staffing issues. Which of the following is the most appropriate next step in management?
- Diagnostic LP
- Initiation of IV antibiotic therapy
- A loading dose of IV corticosteroids
- Aggressive antipyretic therapy
- Sedation of the patient and noncontrast head CT
14. A 22-year-old woman with known IIH who is scheduled for a ven- triculoperitoneal shunt in 2 weeks presents to the ED complaining of severe She states the headache is similar to the normal head- aches associated with her condition except that it is refractor to her regular medications, including triptans and opiates. Her neurologist increased her dose of acetazolamide, but this also did not help. Her noncontrast head CT is unchanged from previous and she does not have papilledema. Which of the following is likely to provide prompt relief?
- IV corticosteroids
- Infusion of mannitol
- LP with removal of 15 cc of CSF
- IV metoclopramide
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
15. A 55-year-old woman with a past medical history of diabetes pres- ents to the ED with fevers, headache, vision complaints, and right-sided weakness. She was treated for otitis media 2 weeks ago with amoxicillin as an You obtain the CT scan seen below. What is the most likely diagnosis?
(Reproduced, with permission, from Schwartz DT, Reisdorff EJ. Emergency Radiology. New York, NY: McGraw-Hill, 2000: 430.)
- Central nervous system (CNS) toxoplasmosis
- Subdural hygroma
- Glioblastoma multiforme
- Brain abscess
16. A 35-year-old woman presents to the ED for the second She is complaining of fever, neck stiffness, and photophobia. She was seen in your ED 2 days ago for the same symptoms. At that time, she had a normal neurologic examination, was otherwise well-appearing, and underwent diagnostic LP. The results of her CSF analysis were as follows:
Glucose 82 mg/dL
Protein 60 mg/dL
WBC 150/L (98% lymphocytes) Gram stain No organisms seen
The patient was sent home after a period of observation with presumed viral meningitis. She was told to return if her symptoms were not better in 48 hours. Since then, her fever increased (100.4°F-102.2°F). What is the next most appropriate step in management?
- Administration of acyclovir
- Aggressive antipyretic therapy and observation
- CT scan of the sinuses
- CT of the head and, if no contraindication, repeat LP
- Viral cultures and polymerase chain reaction (PCR) from previously obtained CSF
17. A 68-year-old man presents to the ED complaining of a daily head- ache for almost a He describes the headache as being dull, difficult to localize, most intense in the morning, and abating in the early afternoon. He also noticed progressive weakness of his right upper and lower extrem- ity. Which of the following headache syndromes are the signs and symp- toms most consistent with?
- Headache caused by a mass lesion
- Cluster headache
- Tension-type headache
- Headache from intracranial hypertension
- Waking or morning migraine
18. A 75-year-old man presents to the ED with a depressed level of con- His wife is at the bedside and states he was stacking heavy boxes when he complained of a sudden intense headache. He subsequently sat down on the couch and progressively lost consciousness. She states that he had a headache the previous week that was also sudden but not as intense. He had gone to visit his primary care physician who sent him to have a CT scan of the brain, which was normal. Over the course of the past week, he complained of intermittent pulsating headaches for which he took sumatriptan. In the ED, you intubate the patient and obtain the noncontrast head CT seen below. The scan is most consistent with which diagnosis?
- Normal-pressure hydrocephalus
- Epidural hematoma
- Subdural hematoma (SDH)
19. A 43-year-old homeless man presents to the ED with fever and nuchal His mental status is depressed, but his neurologic examination is otherwise nonfocal. Noncontrast head CT is normal. You obtain an LP for diagnostic purposes and initiate empiric antibiotic treatment for bacterial meningitis. The result of the CSF analysis is complete after 1 hour. The protein and glucose are within normal range, but the WBC count consists of 220 mononuclear cells. The Gram stain is negative. The patient was recently purified protein derivative (PPD) negative and had a normal chest x-ray. In addition to the treatment already initiated, what is the next most appropriate step in this patient’s management?
- Empiric treatment with isoniazid
- Empiric treatment with antiviral medications for herpes virus
- Empiric treatment with antifungals
- Antibiotic coverage for Bartonella sp
- Addition of steroids to the antibiotic regimen
20. During a busy day working in the ED, five patients come in all of whom you believe require an LP to evaluate for From the fol- lowing list of patients, which one can you forgo a CT scan and proceed directly to an LP?
- A 65-year-old man with fever and headache
- A 49-year-old woman with acquired immunodeficiency syndrome (AIDS)
- A 74-year-old man with new right lower-extremity motor weakness
- A 19-year-old man with a fever who is lethargic and disoriented
- A 51-year-old woman who is febrile and complains of neck stiffness
21. A 53-year-old man presents to your ED stating he has had an excru- ciating right-sided headache since leaving the movie He states that the headache is unilateral, severe, and associated with nausea and vomit- ing. His vision is blurry and notes seeing halos around objects. He denies trauma or a history of headaches in the past. Physical examination reveals right conjunctival injection and a pupil that reacts only marginally. Which examination is likely to yield the correct diagnosis?
- Measurement of intraocular pressure
- Funduscopic examination
- Fluorescein examination
- LP with cell count
- Visual acuity testing
22. A 78-year-old man presents to triage of your ED complaining of gradual onset of headache over the course of the The headache is present almost every day and wonders if it is related to the unusually cold temperatures this winter. He describes the headache as bounding and con- stant. You notice that his face is very ruddy in appearance. He is afebrile but looks rather lethargic and somewhat short of breath. He is afebrile and saturating 100% on pulse oximetry. One of your coworkers informs you that the patient’s wife is in another part of the emergency room with a similar presentation. Two more ambulances arrive, one with a patient com- plaining of a similar headache and another with a patient who is obtunded. All live in the same building. What is the next most appropriate step in the management of these patients?
- Place the patient in respiratory isolation for presumed Neisseria meningitidis infection.
- Draw a blood gas and send it for cooximetry.
- Start antibiotic therapy and perform an LP.
- Treatment for migraine with triptans or IV antiemetics.
- Transfer of all three patients to the nearest hyperbaric facility.
23. A 35-year-old man presents to the ED complaining of a headache over the previous 4 He was assaulted with a bat 4 weeks ago and was admitted to the hospital for observation in the setting of a small traumatic SDH. Repeat noncontrast CT scan of the head 2 weeks ago was normal with resolution of the hematoma. He states he has headaches several times each day. They last from 5 minutes to several hours. They are sometimes band-like; other times they are localized to the site where he was struck. They can be pulsating or constant and are associated with sensitivity to sound. A head CT scan today is normal. Which of the following is the most likely diagnosis?
- Postconcussive syndrome
- Posttraumatic hydrocephalus
- Subdural hygroma
- Cluster headache
- Posttraumatic stress disorder
24. A 35-year-old woman presents to the ED complaining of headache and blurry She has had daily headaches for 3 months associated with blurry vision. She is afebrile, not losing weight, and has a normal neurologic examination, including fundoscopy. You ask when her last men- strual period was and she states she has not menstruated for 5 months and is not taking oral contraceptive pills. She also complains of galactorrhea. Noncontrast head CT is normal. An LP is performed and reveals a normal opening pressure. Which of the following is the most appropriate next step in managing the patient’s headaches?
- Repeat head CT with administration of IV contrast
- Initiation of therapy with bromocriptine
- Evaluation of CSF for xanthochromia and RBCs
- Treatment of her headache with analgesia and an MRI
- Repeat LP with removal of 15-mL CSF for therapeutic benefit